Understanding Workers' Comp

Workers’ comp is not a perfect system, and sometimes things can wrong or fall through the cracks. If an employee filed a valid claim, workers’ comp should cover all their medical expenses resulting from the work-related injury. If anything goes wrong with this process, it is important to find out what went wrong with the claim and get it corrected.

How Does An Employee File For Workers’ Comp Benefits?

An employee should file a workers’ compensation claim as soon as possible after a workplace injury or illness occurs. The process involves the following steps:

Notify you: As soon as possible, the employee should notify you that an accident or illness has occurred. Then provide the following information: date and time the accident occurred; how it happened; and the type of injury sustained.

Complete and submit official paperwork: You will provide the necessary forms for the employee to complete to officially apply for workers’ compensation benefits. Once they have returned the completed paperwork, you will send it to the insurance company for processing. The insurer will then either approve or deny the claim.

Notice of status: The employee will either be presented with an offer for payment of medical and disability costs or receive a notice of denial. If the claim is denied, the employee can choose to appeal or ask the insurer to review the decision.

Why Would Workers’ Comp Fail To Pay Medical Bills?

When workers’ compensation insurance refuses or discontinues medical treatment, it is often for one or more of the following reasons:

The case is being denied for any of a number of possible issues (for example, the incident that caused the injury fails to meet the definition of an accident; or the employee failed to provide the proper notice).

You believe that the condition for which the employee is being treated is preexisting and not the result of a work-related accident or injury.

You believe that the employee has reached maximum medical improvement and no additional medical care is reasonably needed.

You believe the employee has been noncompliant or abandoned medical treatment.

What Happens If Workers’ Comp Is Not Covering Medical Bills?

If your employee is unsure of why their medical treatment has been discontinued or refused or why their medical bills are not being paid, they may request an explanation in writing from the insurance company. Problems often arise because of miscommunication, incorrect or incomplete information, or delays in receiving information. Many problems can be resolved by you and the employee communicating with the insurance company. If not, their next step is to request a conference with an administrative law judge to discuss the concerns.

If an employee has filed a claim for compensation, they may request an evidentiary hearing in which a judge will decide if you are required to cover their medical treatment. They will have the burden of proof and will need to provide medical evidence. In the meantime, they are protected against collection efforts by medical providers if they notify the provider in writing by certified mail that the healthcare services provided involve a workers’ compensation claim.

Workers’ compensation claims can be complicated, so if you are a business owner, it’s important to have the proper workers’ comp insurance in order to protect your company. Contact your local agent today for more information.